Laura's Law will save mentally ill, S.F. budget

MENTAL ILLNESS

Stephen Cummings, Cameron Quanbeck and John Rouse

Published 4:00 am, Sunday, August 1, 2010

Many of San Francisco's most severely and chronically mentally ill spend their lives homeless, pushing shopping carts, talking back to their "voices" and occasionally threatening their fellow citizens. In many ways, their treatment options have never been better, yet their psychiatric condition itself prevents them seeking out or even cooperating with offered treatment.

Ironically, laws enacted in the 1960s to protect the mentally ill from long, needless hospitalizations now keep the sickest out of treatment, leaving them "prisoners of the street" or jailed for behavior caused directly by their disease.

Laura's Law was passed by the California Legislature in 2002. Even though it is a state law intended to apply to all of California's residents, it requires each county to analyze and decide whether to approve the law in its jurisdiction.

San Francisco SupervisorMichela Alioto-Pier has sponsored local implementation of Laura's Law, and it comes before the Board of Supervisors on Tuesday for a vote. If enabled, it will allow the most seriously ill and dangerous patients to be brought to the hospital before their lives collapse or they harm themselves or others.

Kendra's Law (Laura's "big sister") has been in effect in New York City since 2001. It has resulted in huge savings in terms of taxpayer expense (for emergency visits, long hospitalizations and jailing) and, more important, in documented benefits to the patients themselves, who feel less coerced and stigmatized by their psychiatric treatment and are more likely to accept treatment on their own after the program. If San Francisco supervisors vote to enact Laura's Law, they will be not only leaders in the Bay Area but also will set an example for the rest of the West Coast. In many ways, severe mental illness is just like myriad other chronic diseases. Untreated, conditions such as diabetes, asthma and HIV infection - and schizophrenia - often lead to terrible suffering, repeated hospitalizations and, ultimately, permanent disability or death. But with continued treatment, people with these diseases can live long, satisfying lives.

What's different about serious mental conditions, though, is that the illness strips some victims of the ability to realize they need help - or even to know they are sick. Brain diseases such as schizophrenia and bipolar disorder can attack parts of the brain responsible for self-awareness and insight. The disease itself makes the person believe that nothing is wrong.

That's why Laura's Law is necessary. Under current law, people with mental illness can refuse to take medicines if they like, except when they are extremely ill, even though the illness must be treated continuously to minimize the risk of acute episodes and permanent disability. Yet the disease takes away the person's ability to make a rational decision about treatment. It's like giving people with Alzheimer's disease and diabetes glucometers and insulin and expecting them to monitor their blood sugar and give themselves insulin when needed. Inevitably, they forget they have diabetes, and their blood sugar skyrockets. They finally receive life-saving insulin only when they are in a diabetic coma.

Psychiatrists do the same with the severely mentally ill - over and over and over again. It just doesn't make sense. The devastation caused by untreated mental illness is enormous and deeply affects individuals, their families and our communities. People with these conditions often suffer extreme anguish; they can be beset by terrifying hallucinations, paranoia and confusion, they can lose the ability to function at work or in school, and they often drive away - or flee from - those they love. Acute symptomatic episodes lead to brain damage, often permanent. Violence is another consequence.

Those with untreated mental illness are the victims of assault, rape and other brutalization much more often than the rest of us, they are much more likely to kill themselves, and they perpetrate more violence as well. And mental illness also leads to serious physical health problems, shortening life expectancy by 25 years, according to some studies.

Obviously, there are good reasons to be wary of any proposed infringements on the right to make our own decisions about health care. Mental illness in particular is fraught with complications. The argument for Laura's Law would be stronger if psychiatrists (like those pharmaceutical-sponsored TV commercials touting the latest cure-all antidepressant) could claim that their medicines always work - they do not; or that they are completely safe - they are not. And given the tendency toward medical arrogance and the historical examples of inappropriate psychiatric treatment, we shouldn't give doctors the final say about who gets involuntary treatment.

That's why Laura's Law contains strong safeguards. Under the law, medications can be involuntarily administered only when all these conditions are met:

-- The person must have been hospitalized for a severe mental illness and stabilized on medication.

-- A legal hearing must be held while the person is hospitalized to determine whether criteria for Laura's Law are met. The person has representation at the hearing. Laura's Law goes into effect only if the judge decides that the law applies.

-- After the person is released to the community but stops taking medication and begins to relapse, he or she can be brought back to the hospital for assessment. If at that point the person refuses medication, a psychiatrist can call for another hearing only after determining that the relapse is related to the stopping of medication and that the person lacks the capacity to make an informed decision to refuse.

-- Finally, that second hearing is held to review the psychiatrist's assessment. Only if the hearing officer determines that the individual doesn't recognize that stopping medication led to the relapse can medication be given involuntarily.

As psychiatrists, we worry that the complexities of this process will still mean harmful interruptions and delays in treatment for many people with mental illness. But Laura's Law is a giant step in the right direction. It offers many more people hope for proper treatment - and for freedom from the ravages of chronic mental illness.

Laura's Law is not a draconian measure that robs people of their civil liberties; it is cost-effective and preventive medicine, plain and simple.

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